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How to provide specialist services: how do we know when centralisation is a good idea?
  1. Stuart Michael Crawford
  1. Research, Airedale NHS Foundation Trust, Keighley, UK
  1. Correspondence to Stuart Michael Crawford, Clinical Lead for Research, (Formerly Consultant Medical Oncologist), Airedale NHS Foundation Trust, Skipton Road, Steeton, Keighley BD20 6TD, UK; S.M.Crawford{at}

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As research identifies new ways of caring for patients, services must develop to ensure that knowledge is applied. It is tempting to argue that this is best achieved if patients are managed by a team that has specialist skills even if its location is remote from the patient’s home. Indeed, the Health Services Journal reports that fundamental changes to London’s Nationa Health Service (NHS) are being considered by NHS England and Improvement London in the wake of COVID-19. Centralisation of specialised services is reported to be part of the thinking. Careful consideration of its full effects is lacking in some studies that seek to evaluate centralisation.


In the 1970s, Indiana University (IU) established a worldwide reputation for developing curative treatment of testicular germ cell tumours. In 2018, Albany et al of the IU team published a paper arguing outcomes were better when services were provided by a centralised multidisciplinary team.1 They used data from their own experience compared with data from the rest of the state of Indiana showing a survival advantage for those treated in the IU facility.

This conclusion was not valid. For example, an entry criterion for the IU series was to have received the first cycle of chemotherapy there. The entry criterion for control group was surviving at least 1 day. This amounts to an enormous disparity between the two groups quite sufficient to account for a survival advantage.

The IU team also includes a supplementary map to show the wide geographical area within the Eastern USA and beyond from which they attract patients. Herein is a further source of bias; the act of electing to travel to an institution of high repute requires socioeconomic resources and sufficient wellness to make the journey, which implies a significant potential chance of a superior clinical outcome over …

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  • Contributors SMC is the sole author of this article.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review This article reflects my clinical experience of practising a speciality, medical oncology, which in the UK is predominantly based in teaching hospitals. I have developed a service in a district general hospital serving a small-town and rural population. I have pursued a research interest in patients’ access to diagnosis and treatment of cancer, largely in collaboration with non-clinical colleagues in the University of East Anglia.